Development Of A Diagnostic Scale For Depression With Liver Depression And Qi Stagnation Syndrome And Serum Metabolomics Stud

Objective:1.Under the guidance of TCM theory,establish a diagnostic scale for depression with liver depression and qi stagnation syndrome with reasonable items,objective indicators,and strong operability according to the standard formulation process,and clarify the primary and secondary symptoms,item weights,and diagnostic thresholds of the syndrome.Provides rigorous quantitative tools for evidence-based diagnosis.At the same time,the diagnostic test and evaluation of the reliability and validity of the diagnostic scale for liver depression and qi stagnation syndrome in depression were carried out,so as to provide standardized and reliable evidence for syndrome differentiation for the promotion of standards and clinical guidance.2.Use non-targeted metabolomics technology to explore potential metabolic biomarkers of depression with liver depression and qi stagnation syndrome,reveal the intrinsic pathological state of the syndrome,and facilitate early identification and accurate quantitative analysis of the syndrome.Methods:1.Development of the diagnostic scale for liver depression and qi stagnation syndrome in depression:establish a literature database,and build a question bank based on the literature database;through 3 rounds of Delphi expert consultation,including support,mean,full score ratio,grade and,unimportant Subjective items were screened by percentage and coefficient of variation;compared with the three weighting methods of AHP,factor analysis,and comprehensive weighting method,the optimal weighting method was selected to determine the weight of items;The degree of syndrome classification was determined by quantile method;then the criteria were evaluated by indicators such as sensitivity and specificity of diagnostic tests.In order to reflect the clinical credibility,various statistical methods such as stepwise regression analysis,item distribution test method,discrete trend method,correlation coefficient method,factor analysis method,and Cronbach’s a coefficient method were used to screen and optimize the target items.The reliability of the criteria was verified using reliability and validity methods.Reliability includes internal consistency reliability and halfway reliability.Validity includes content validity,construct validity,convergent validity and discriminant validity.2.Study on serum metabolomics of depression with liver stagnation and stagnation of qi:Using serum metabolomics method,using ultra-high performance liquid chromatography-mass spectrometry(UHPLC-QE-MS)technology to analyze the syndrome of stagnation of liver and qi in depression and serum samples of depression patients with severe liver depression and qi stagnation,screened serum metabolites,and obtained potential biomarkers and related metabolic pathways of patients with depression and severe liver depression and qi stagnation.ROC analysis was used to judge the predictive ability of differential metabolites for depression with liver depression and qi stagnation syndrome and depression with severe liver depression and qi stagnation.Results:1.Development of the diagnostic scale for depression with liver depression and qi stagnation syndrome:(1)Establishment of literature databases:From the date of establishment of each database to October 31,2020,a total of 7,488relevant literatures were retrieved,according to the inclusion and exclusion criteria According to the requirements of the initial screening(read the title and abstract),6997 articles were removed and 393 articles were removed by the secondary screening(reading the full text),and finally 98 articles that met the requirements of liver depression and qi stagnation syndrome were left,and the symptoms,signs and tongue pulse conditions were extracted respectively.After statistical frequency analysis,a diagnostic item information table for liver depression and qi stagnation syndrome was developed,and symptoms with a frequency greater than 15 were selected as the item pool.(2)Delphi method expert consultation:carry out 3 rounds of expert questionnaire survey,each round adopts support degree≤50%,average value≤2,full score ratio≤30%,grade sum≤30%of full score,unimportant percentage>80%,The coefficient of variation>0.3 was used to screen the entries,and the entries were deleted if they met 3 of the 6 items in the above screening method.In the first round,the item"red tongue"was deleted,and the experts proposed to add the item"dark tongue";in the second round,the items"insomnia","constipation and constipation"and"thin yellow fur"were deleted,and the expert proposed to add the item"stringent pulse";In the third round,delete the entry"dark tongue".A total of 84 experts participated(15 in the first round,32 in the second round,and 37 in the third round),and the total expert positive coefficient was 99%.The final 12 items will be obtained after statistical analysis and two expert consultation results,and 8 items in the symptom dimension(including main symptoms and secondary symptoms),which are fullness(fullness)or distending pain or pain(chest and flank,low abdomen),breasts,etc.),emotional depression,breathing,etc.;tongue and pulse dimension(including tongue and pulse)4 items,respectively,light red tongue,thin white fur,stringy pulse,etc.(3)Comparison of weighting methods:AHP is used for subjective weighting of items,factor analysis is used for objective weighting of items,the product of the two is used for comprehensive weighting of items,and then the area under the ROC curve is compared.Objective weighting method(0.824)>subjective weighting method(0.798)>comprehensive weighting method(0.796),so the objective weighting method is selected to construct the item weight,and the weight of the main symptom item is:fullness(boring)or pain Or pain(thorax,lower abdomen,breast,etc.)4 points,emotional depression 3 points,the weight of secondary symptoms:irritability 2 points,too much breath 3 points,foreign body sensation in the pharynx 4 points,irregular menstruation 5 points 5 points,dysmenorrhea 5 points,easily induced or aggravated by emotional distress 2points,the weight of the tongue image item is:light red tongue 5 points,thin white fur 2 points,the weight of the pulse condition item:stringy pulse 6 points,pulse Shen Xian scored 5 points.The diagnosis mode was determined according to the expert interview:2 main symptoms+at least 1 secondary symptom(6items in total)+at least 1 category of tongue pulse condition.(4)Diagnostic threshold:According to ROC curve analysis,the diagnostic threshold of the largest Youden index was selected as the standard diagnostic threshold,and the threshold was 20 points after proportional expansion.Diagnostic criteria grading:20 points≤points<24 points for mild liver-qi stagnation syndrome,24 points≤points≤31 points for moderate liver-qi stagnation syndrome,and points>31 points for severe liver-qi stagnation syndrome.The established diagnostic criteria for syndromes will be promulgated in the group standards of the China Association of Traditional Chinese Medicine in March 2023.2.Diagnostic test for depression with liver depression and qi stagnation syndrome:116 mild and moderate depression patients were included in this study,and the constructed sensitivity was 88.16%,specificity was 80.00%,accuracy was 85.34%and Kappa value was 0.68,indicating that the judgment results of the standard and the doctor’s judgment results have a strong consistency,suggesting that the diagnostic scale for depression with liver depression and qi stagnation syndrome has good diagnostic efficiency.3.Evaluation of the diagnostic scale for liver depression and qi stagnation syndrome in depression:the items of the diagnostic scale for depression and liver depression and qi stagnation syndrome were analyzed by stepwise regression analysis,item distribution inspection method,discrete trend method,correlation coefficient method,factor analysis method,Krona Bach’s a-coefficient method and multiple statistical methods were used to objectively screen the items.After various statistical analyzes and expert meeting discussions,the item"pulse string"was deleted,and the remaining items were evaluated for reliability and validity measurement performance.The internal consistency reliability Cronbach’s Alpha coefficient is 0.701,and the split-half reliability Spearman-Brown coefficient is 0.757,indicating that the reliability of the scale is good.Validity I-CVI(content validity index at item level)is0.71-1.00,and S-CVI(content validity index at scale level)is 0.92,which shows that the content validity of the scale is good.Confirmatory factor analysis of construct validity shows that the ratio of X~2/df is 1.459,the RMSEA value is0.078,and the GFI,AGFI,CFI,IFI,and TLI values are respectively:0.886,0.817,0.859,0.872,and 0.810,indicating that the structural model fits The degree is better.The convergent validity of the symptom dimension and the tongue pulse condition dimension of the scale are 0.658 and 0.723 respectively,indicating that the convergent validity of the scale is good.The HTMT method was used to test the discriminant validity between the two dimensions of the scale.The HTMT value was 0.483,indicating that the internal discriminant validity of the scale was qualified;The scores of the scale for patients with liver depression and qi stagnation(8.90±3.24),and the difference is statistically significant,indicating that the scale has good external discriminant validity,and can well distinguish liver depression and qi stagnation syndromes from non-liver depression and qi stagnation syndromes crowd.4.Serum metabolomics study of depression with liver depression and qi stagnation:A total of 28 cases were included in the depression group with liver depression and qi stagnation,and 30 cases in the healthy group.According to serum metabolites,79 differential metabolites were screened out,of which 53small molecule metabolites were down-regulated in depression with liver depression and qi stagnation syndrome:2-Ethyl-5-methylpyridine,2-Methylpyridine,Acrylamide,etc;26 small molecular metabolites are up-regulated in depression with liver-qi stagnation syndrome:5,7alpha-Dihydro-1,4,4,7a-tetramethyl-4H-indene,Adenosine,3-Hydroxy-beta-ionone,etc.Through KEGG enrichment analysis of differential metabolites,the most correlated pathways were:D-Glutamine and D-glutamate metabolism,Glycine,serine and threonine metabolism.On the other hand,seven kinds of 2-Ethyl-5-methylpyridine,2-Methylpyridine,Acrylamide,L-Alanine,Taurine,Leucine-phenylalanine,and Mandelic acid were screened.The areas under the ROC curve of the differential metabolites were 0.989,0.985,0.969,0.927,0.939,0.795,and 0.817,respectively,which can be used as potential biomarkers for depression with liver depression and qi stagnation.5.Serum metabonomics research on severe liver depression and qi stagnation in depression:According to the grading of the diagnostic criteria for depression and liver depression and qi stagnation,there were 8 cases of severe 8cases of liver depression and qi stagnation syndrome.According to the OPLS-DA analysis of pairwise comparisons of syndrome levels,only the Q2 of the severe liver depression and qi stagnation group versus the mild liver stagnation and qi stagnation group of depression is greater than 0.4.Therefore,the research of this group will be further analyzed.Compared with the depression group with mild liver depression and qi stagnation,there were 53differential metabolites in depression with severe liver stagnation and qi stagnation,including 39 metabolites,such as Deoxycholic acid,Creatinine,and L-Valine,whose levels were down-regulated.The levels of 14 metabolites includingIsopropylbenzene,2-(3-Phenylpropyl)tetrahydrofuranand3-Hydroxy-beta-ionone were up-regulated.Pathway analysis was performed based on screened differential metabolites,mainly involving the Valine,leucine and isoleucine biosynthesis.ROC analysis of differential metabolites showing D-alpha-Aminobutyric acid,Symmetric dimethylarginine,Aspartame,Dihydroresveratrol,Arginyl-Alanine,N-Acetyl-L-alanine,Glyceric acid,and Nandrolone are relatively good at distinguishing depression from severe liver depression and qi stagnation,and the areas under the ROC curve are 0.859,0.875,0.859,0.844,0.875,0.875,0.797,and 0.813,respectively.Conclusion:1.Under the guidance of TCM theory,through establishment of database to determine item pool,3 rounds of Delphi expert consultation to screen items,optimal weighting method to establish item weight,ROC curve to determine diagnostic threshold,formulate the diagnosis of depression with liver depression and qi stagnation syndrome Scale,and promulgated in the group standards of the China Association of Traditional Chinese Medicine(see the official account of standardization of traditional Chinese medicine for details).Among them,the main symptom and weight of the scale are:fullness(suffocation)or distending pain or pain(chest and side,lower abdomen,breast,etc.)4 points,emotional depression 3 points,and the secondary symptoms and weight are:irritability and irritability 2 points,too much breathing 3 points,foreign body sensation in the pharynx 4 points,irregular menstruation 5 points,dysmenorrhea 5 points,2 points easily induced or aggravated when emotional disturbance occurs,tongue image and weight are:pale red tongue 5 points,fur Thin white 2 points,pulse condition and weight:pulse string 6 points,pulse deep string 5 points,diagnostic threshold:score≥20 points,syndrome established,diagnostic mode:2 main symptoms+at least 1 secondary symptom(6 items in total)+Tongue pulse condition of at least 1 category.2.Through the investigation of 116 clinical cases,it is shown that the scale has good diagnostic efficiency and reliability and validity evaluation,and provides a standardized and reliable evidence for syndrome differentiation for the promotion of standards and clinical guidance.3.The metabolic process of depression involves multi-level metabolites such as amino acid metabolism,glycerophospholipid metabolism,and energy metabolism.Screened serum metabolites 2-Ethyl-5-methylpyridine,2-Methylpyridine,Acrylamide,L-Alanine,Taurine,Leucine-phenylalanine,and Mandelic acid for depression Biomarkers of liver depression and qi stagnation syndrome,the pathological changes may be related to neurotransmitter disorders and oxidative stress damage;the screened serum metabolites D-alpha-Aminobutyric acid,Symmetric dimethylarginine,Aspartame,Dihydroresveratrol,Arginyl-Alanine,N-Acetyl-L-alanine,Glyceric acid,and Nandrolone as biomarkers of severe liver depression and qi stagnation in depression,may be related to neurotransmitter disorders and energy metabolism disorders.